Provider Demographics
NPI:1174873715
Name:MCCARTHY, COLLEEN (RD, LD, CLT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:RD, LD, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12850 HIGHWAY 9 N
Mailing Address - Street 2:SUITE 600-180
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-4231
Mailing Address - Country:US
Mailing Address - Phone:678-404-7442
Mailing Address - Fax:
Practice Address - Street 1:12600 DEERFIELD PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-6108
Practice Address - Country:US
Practice Address - Phone:678-404-7442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003946133V00000X, 133VN1004X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic